625996

research-article2016
GQNXXX10.1177/2333393615625996Global Qualitative Nursing ResearchScholtz et al.

Article

Global Qualitative Nursing Research

The Culture of Nurses in a

Volume 3: 1­–11
© The Author(s) 2016
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DOI: 10.1177/2333393615625996
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Suegnèt Scholtz1, Elsabe W. Nel1, Marie Poggenpoel1,

and Chris P. H. Myburgh1

Abstract
Critical care nurses have to adapt to a fast-paced and stressful environment by functioning within their own culture. The
objective of this study was to explore and describe the culture of critical care nurses with the purpose of facilitating
recognition of wholeness in critical care nurses. The study had a qualitative, exploratory, descriptive, and contextual design.
The ethnographic study included data triangulation of field notes written during 12 months of ethnographic observations, 13
interviews from registered nurses, and three completed diaries. Coding and analysis of data revealed patterns of behavior
and interaction. The culture of critical care nurses was identified through patterns of patient adoption, armor display,
despondency because of the demands to adjust, sibling-like teamwork, and non-support from management and medical
doctors. An understanding of the complexity of these patterns of behavior and interaction within the critical care nursing
culture is essential for transformation in the practice of critical care nursing.

Keywords
ethnography, exploratory methods, intensive care unit (ICU), observation, participant, triangulation

Received July 7, 2015; revised December 1, 2015; accepted December 7, 2015

Critical decisions, highly stressful situations, and ethical practice their profession in the critical care environment after
dilemmas are all part of the unique environment of a critical 20 years (Scribante & Bhagwanjee, 2007). In developing
care unit (CCU). Despite this harsh reality, there are those countries, nurses are central to and in some ways the most
who choose to work within this environment. Critical care visible part of health care services. They have their own
nursing focuses intensively on all aspects of basic nursing responsibilities when it comes to patient care and often take
care and life support, and thus combines the essence of nurs- on responsibilities usually afforded to physicians (Singh,
ing with observation, insightful and even intuitive interpre- Nkala, Amuah, Mehta, & Ahmad, 2003).
tation, and reactions to the slightest imbalance or deviation The World Health Organization (2006) accentuated the
in a patient’s condition (Urden, Stacy, & Lough, 2006). In need for increased efforts to improve the performance of the
their efforts to provide quality care to critically ill patients, existing health workforce and to slow the rate at which pro-
critical care nurses have to face many challenges within fessionals leave health care services. There is also currently
their working environment (Drews, 2013). Pretorius (2009) an emphasis on patient-centered care, which within the con-
acknowledged the effect of this unhealthy work environ- text and complexity of a CCU adds to existing physical and
ment on critical care nurses and promotes a positive practice intellectual challenges (Schluter, Winch, Holzhauser, &
environment as the foundation for successful recruitment Henderson, 2008). Nurses are required to meet the physical,
and retention of critical care nurses. It is not only the envi- psychological, and even spiritual needs of their patients.
ronment but also experiences which play an important role Towell (2011) stated that critical care nurses embody dimen-
in their intent to stay within a CCU or even the profession sions of mind, body, and spirit and function effectively—
(Cummings, 2011). holistically—within their environment. Towell further
Cummings (2011) found within a year of her study that
33% of nurses working within acute care settings intended to 1
University of Johannesburg, Johannesburg, South Africa
resign. In the public sector of South Africa where this study
was conducted, there are only 0.3 CCU trained nurses per Corresponding Author:
Suegnèt Scholtz, University of Johannesburg, 6th Floor, West Wing
CCU bed. Most of these nurses (42.8%) have a maximum of North, John Orr Building, Doornfontein campus, Johannesburg, Gauteng
5 years of nursing experience (Scribante & Bhagwanjee, Province, South Africa.
2007) and only 5.7% of nurses in South Africa continue to Email: [email protected]

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2 Global Qualitative Nursing Research 

identified emotional intelligence as a problem in critical care of an environment assists members of that culture to deter-
nurses and stated that emotional intelligence contributes to mine what is important in a situation, how interactions should
wholeness. It is this concept which led to the idea that poor take place, and in what ways they can affirm their beliefs,
performance, the lack of patient-centered care, and nurses values, and norms.
leaving the profession are symptoms of a greater problem. Research consistently ventures to describe or explain the
Wholeness, consciousness, and caring are concepts asso- experiences, perceptions, and actions of critical care nurses
ciated with the theoretical perspectives of nursing, with in their work environment, including perceptions of ethical
wholeness as the starting point for nursing praxis (Cowling, problems, futile care, and end-of-life care, which was found
Smith, & Watson, 2008). According to Buechner (1993), to be the greatest ethical and moral issue for both physicians
each person carries an internal vision of wholeness inside of and nurses (Attia, Abd-Elaziz, & Kandeel, 2012; Çobanoğlu
him or her, reflecting a true version of humankind. Human & Algier, 2004; Gaudine, LeFort, Lamb, & Thorne, 2011;
beings are “whole” beings, but perceptions and experiences Hov, Hedelin, & Athlin, 2007; Palda, Bowman, McLean, &
can cloud this reality. According to Cowling et al. (2008), Chapman, 2005; Sibbald, Downar, & Hawryluck, 2007).
“Caring cleanses the doors of perception so that we can see Findings from research on staffing issues in acute care sug-
ourselves and others as they are—whole” (p. 45). Through gest that an effective patient–staff ratio within CCUs is
caring, critical care nurses need to see themselves and others mostly one nurse to one patient, but the ratio may be higher
as whole. where staff shortages are experienced. Research also shows
Newman (2003) referred to wholeness as a pattern and that understaffing, or unqualified staff assigned to a CCU to
healing as the process of recognizing this pattern. According correct shortages, can increase the responsibility and stress
to Cowling et al. (2008), once one recognizes the pattern, it levels of critical care nurses (Bray et al., 2010; Cummings,
will encourage transformation. Becoming more aware of 2011; Gurses & Carayon, 2005; Tschannen & Kalisch, 2008).
wholeness as a pattern facilitates growth in caring and love In recent research, moral distress, obligations, and work
for others and the self (Cowling et al., 2008). Nursing responsibilities of critical care nurses were studied. Findings
involves a consciousness of wholeness, as well as meaning identified a need to support nurses in difficult critical care
in nurse–patient experiences which establish an organized situations (Burston & Tuckett, 2012; Cronqvist, Theorell,
existence for the nurse as a person, being integrated with the Burns, & Lϋtzén, 2004; McGibbon, Peter, & Gallop, 2010;
environment (Cowling et al., 2008). Schluter et al., 2008; Wiegand & Funk, 2012). We found sev-
Critical care nurses cannot be separated from their experi- eral individual issues and performance obstacles within the
ences in critical care or from the world which they are expe- critical care nurses’ work environment (Drews, 2013;
riencing. They are present in their experience of the present McGettrick & O’Neill, 2006; Ulrich et al., 2007), with litera-
(Newman, 2003). Therefore, meaning and consciousness of ture supporting critical care nurses’ attitudes and attributes
the pattern of wholeness can only come from expanding our regarding critical care (Evans et al., 2010; Henneman et al.,
knowledge about critical care nurses within a CCU. To rec- 2010; Hensel, 2011; Hughes, 2012; Mullarkey, Duffy, &
ognize the pattern of wholeness, critical care nurses need to Timmins, 2011).
know their own critical care nursing cultural values within Critical care nurses and their relationships with patients or
the critical care environment (Evans, Bell, Sweeney, Morgan, the patients’ families were recently studied (Comrie, 2012;
& Kelly, 2010). Finally, Meyer (1989) viewed wholeness as Hickman, Daly, Douglas, & Burant, 2012; Kim, Yates,
a synonym for the Biblical perspective of peace and defines Graham, & Brown, 2011; O’Connell, 2008; Price, 2013;
it as harmony in relationships; a person’s experience of life; Vandall-Walker & Clark, 2011; Vouzavali et al., 2011); their
an emotional awareness and an awareness of other people in working relationships with other medical professionals also
the community; well-being; abundant and righteous living. form part of the existing literature (Fray, 2011; Schmalenberg
According to Cowling et al. (2008), this inner peace directs & Kramer, 2007; Stein-Parbury & Liaschenko, 2007). It is
the nurse’s consciousness toward caring. clear that researchers studied many separate elements within
The research questions that arose from this problem state- the critical care environment and individual aspects of criti-
ment were as follows: cal care nursing, but there are no explorations into the culture
of critical care nurses. The purpose of this article—the explo-
Hypothesis 1: What is the culture of critical care nurses ration and description of the culture of nurses in a CCU—is
in a CCU? limited to answering the first research question.
Hypothesis 2: What can be done to facilitate recognition
of wholeness in critical care nurses?
Method
The critical care environment contributes to a culture of To understand the critical care nursing culture, this study
critical care nurses which have distinctive social patterns, focused on critical care nurses within the context of a CCU. A
different from the mainstream of nursing (Leininger, 1997). qualitative design—more specifically an ethnographic study—
According to Dodek, Cahill, and Heyland (2010), the culture was chosen, coinciding with a post-modern constructivist
Scholtz et al. 3

philosophy of science. This implied that understanding the of off-duty time. The introductory question for the interviews
meaning of the culture of critical care nurses was explored was as follows: How do you experience working in this
through participants’ views and their interactions with one CCU? The interviews were then structured around rich
another, predicting the need for an in-depth exploration points (Agar, 2004), which the researcher found during her
(Creswell, 2013; Denzin & Lincoln, 2011). Research com- observations and fieldwork. She directed the conversation
menced after ethical clearance was provided by an Academic with her observations in mind, without imposing too much
Ethics Committee. structure on the interaction but conversed with participants
to clarify and attach meaning to her observations.
A process of data triangulation was used to ensure that
Sample multiple realities of the case could be explored to provide a
The purposively selected 10-bed general CCU received cultural description and for the purposes of validation.
mostly adult medical or surgical patients and pediatric Extracts from observations, which included sensory percep-
patients, in exceptional cases. Within this unit, all qualified tion and field notes, also included the researcher’s impres-
and experienced registered critical care nurses were purpose- sions and insight during data collection. Data from participant
fully included to participate in an in-depth study into their diaries and transcripts of conversations of in-depth, open-
work lives. Regular agency staff was also included in the ended interviews were autobiographical and provided a
study. The final sample consisted of all registered nurses unique vantage point of the individual in the CCU culture,
(RNs)—working within the CCU—who had given their con- verifying the interpretations and meanings of rich points
sent. The occurrence of data saturation predicted the number observed during fieldwork. The data had the same focus but
of interviews necessary for this research. According to Guest, provided diverse views of the culture under study.
Bunce, and Johnson (2006), data saturation occurs at the Audiotaped interviews, personal diaries, and field notes
point when new data produce minimal changes to the codes. were stripped of identifiers, including names and dates. A
This point was reached after 13 interviews. password and data encryptions were used to protect elec-
tronic data, and raw material and data were kept secure.
Data Collection
Analysis
The researchers discussed the purpose and objectives of the
study with the participants during a general meeting. All the Data collection and analysis took place concurrently. The
nursing staff working within the unit agreed to the presence analysis processes described as a spiral by Creswell (2013)
of a researcher as an observer and gave written informed were used to organize the data. It involved filing data into
consent. One of the researchers, who was a practicing critical segments that were easy to retrieve. All transcripts were
care nurse with a master’s degree in nursing, availed herself carefully read in conjunction with the identification of rich
to participate as a CCU nurse in the selected unit on two points and a content analysis of the data. The researchers
occasions prior to the study and twice during the study. The took notes throughout this process to obtain a sense of all the
dual purpose for becoming a participant was to familiarize collected data. The coding process involved a combination
her with the setting and to make contact with the participants of techniques, including the identification of rich points
in a non-threatening way—from the inside. She became part which piqued the researcher’s curiosity about other possible
insider and part outsider, providing an opportunity to be a connections, explanations, and meanings, resulting in further
part of the observed culture, while remaining distant exploration and reflection (Agar, 2004). After all transcripts
(Creswell, 2013). This enabled her not only to participate but had been carefully reread, they were coded. These codes
also to step back and reflect on the rich points she observed became a list which fell into patterns.
(Agar, 2004). She visited the unit regularly during weekdays, The next step involved making a list of smaller patterns,
on occasional weekends, and during night duty. The then clustering them together, highlighting those patterns
researcher observed and made field notes and conversed with that represented information which the researcher expected
these nurses within their work environment for 1 or 2 days in to find and information that could be described as being
a week during a period of 12 months. unique (Creswell, 2013). These patterns and explanations
The researcher decided to hand out diaries during the sec- were then actively sought out, followed by a search for evi-
ond month of observation. Participants, who voluntarily dence in the data to support these codes. The data were read
agreed, kept a diary for 1 month. They needed to fill in the through once more to find good descriptions of the behavior
diary daily, preferably after a work shift, as well as on their and other cultural aspects presented by the codes (Creswell,
off-duty days. They could write anything pertaining to their 2013).
work lives. Eleven diaries were handed out, of which three The process continued by classifying the data and identi-
returned as completed. The researcher planned and sched- fying cultural patterns which described how the culture-shar-
uled formal, open-ended interviews with participants and ing group worked (Creswell, 2013). The codes were named
conducted them in a private setting. It took about 1½ hours to provide the best description of these cultural patterns. A
4 Global Qualitative Nursing Research 

detailed description, or “thick description” (Denzin, 1989, the well-being of their patients. They enjoyed the challenges
p. 83) of the reality of the critical care nursing culture, of caring for a very ill patient. It was important for them to
included the cultural aspects and meanings derived from the feel that they had made a difference and to experience the
data analysis. improvement in their patients; as another nurse stated, “The
The final step was to assess whether the existing data patients come back once they have been discharged . . . and
should be recoded (Tesch, 1990). The data were also coded you think . . . fantastic, patient made it.”
by an independent consultant, with a PhD in nursing, who These critical care nurses seldom regarded patients as a
had found similar patterns. Meanings were attributed and negative consequence of nursing in a CCU. They became
validated by participants from the critical care culture. The upset about all the things that opposed or threatened patient
final results were compared with the results of the existing care, for example, disagreements among doctors over patient
literature. treatments and dysfunctional family members trying to inter-
fere with procedures or care, while ignoring the patient’s
condition. Another example of this was incompetent nursing
Findings
staff looking after very ill patients or understaffing which
At the time of this research, there were only female nurses caused nurses to feel they had neglected a patient who needed
working in the selected unit. The RNs who participated more intensive care. This is evident by the following state-
ranged in ages from 25 to 55 years, with an average age of 42 ment: “I don’t like to feel like I neglect a patient.”
years. They had between 1 and 23 years of experience in Critical care nurses experienced the importance of being
critical care nursing. Ten of these nurses had additional train- able to give of themselves to their patients. The critical care
ing in critical care, and three had experience in CCUs but nurse took responsibility for the patient’s care, nurtured and
with no additional training. protected the patient. In short, the critical care nurse adopted
Five patterns of behavior and interaction revealed the cul- the patient. This was also very evident in the compassion
ture of critical care nurses, representing a holistic cultural and concern displayed by critical care nurses toward their
portrait. Each pattern contains categories that describe its patients.
characteristics and meaning. These patterns of behavior and
interaction include patterns of patient adoption, patterns of Critical care nurses’ behavior and interaction influenced by the
armor display, patterns of sibling-like teamwork, patterns of role of a CCU patient’s family.  Critical care nurses made room
despondency due to the demands of adjusting to the critical for the critically ill patient’s family but needed to give undi-
care environment, and patterns of non-support from manage- vided attention to their patients. Patients who were critically
ment and the medical doctors. ill were not always able to deal with their family members
and were mostly too ill to enjoy the visiting times. If a patient
Patterns of Patient Adoption became unstable, the critical care nurses would put the
patient’s well-being first and ask the family to leave for them
Patient adoption was the term provided for the pattern of to take control of the immediate threat to the patient. One
behavior and interaction observed when critical care nurses nurse stated, “The visitors sometimes take more of your time
take care of a patient. It became evident that the patient is the and attention than the patient.”
primary focus and reason for any nursing action within the Critical care nurses provided situational support to the
CCU. family when it was warranted, for example, with a new
admission, after a patient emergency had occurred, and with
Critical care nurses focus on their patients.  After the initial con- the death of a patient. They showed sympathy for the patient’s
tact between the critical care nurse and her patient, the nurse family and even made exceptions to the rules during visiting
assumed responsibility for the patient’s care. This is a unique hours. One nurse stated,
interdependent relationship which necessitates a very fast
adjustment to the boundaries and responsibilities between And she yelled at me—I’m a racist bitch . . . Then I thought to
the nurse and the patient. Many nurses have mentioned “the myself, you know this poor woman . . . You must know, I never
patient” to be the only, most important, and most rewarding took it personal . . . It’s not many people who have to hear that
side to their work. Critical care nurses were attracted to the your husband is going to die.
concept of total patient care. One nurse stated, “For that
twelve hours you wash him, you do everything, you give There were a mutual focus and understanding between the
medication and observe the patient. I like that.” critical care nurses and the patient’s family. The patient’s
Focus was their primary objective, and for the critical care family was a very important part of, and could not be sepa-
nurses, witnessing the effects of “going all out” about patient rated from, the patient. They posed some challenges to the
care was what translated into job satisfaction. Critical care nurses who needed to involve them in decisions regarding the
nurses in this study saw their input into a patient’s care as patient’s treatment or care plan. There was also a matter of
necessary and important, to both their own well-being and role adjustment with regard to their family member’s illness.
Scholtz et al. 5

Critical care nurses were often required to be mediators found that they would display their powerlessness in a
between family members who could not cope with the situation—verbally or even non-verbally—by sighing aloud
patient’s illness and their own issues, while visiting. They or rolling their eyes.
did not like to become involved in family feuds, but some-
times this might be unavoidable. Nurses in this study did not Coping skills and adaptation are a part of critical care nurses’
like to go into technical details or even diagnostic details armor display. One nurse stated, “You learn to adapt . . .
about readings on the equipment used in the treatment of you’ve got to be a strong person.” To talk about it and not to
their patients as noted in this statement: “It’s about the patient talk about it were both used as coping skills. Work-related
at the end of the day. So he must visit with the patient, he did issues were discussed with either family or colleagues, but
not come to visit the monitor.” alternative help or counseling was rarely used—even in light
Even though the nurse adopts the patient, the role of the of statements like these: “How do we cope when you have to
critically ill patient’s family influenced critical care nurses’ go out and tell a mother that her child is dead? How do you
behavior and interaction with the patient and the family. do it?”
Emotions that are heaped up will sometimes be vented at
home or even at work. They either have or develop a strong
Patterns of Armor Display
determination and cope by staying in control: “Press through
The term armor display is used metaphorically. Armor is (laugh), because there is no other way.” Humor was used as
described in the dictionary as a defensive, protective cover- a way of coping with the CCU environment and by telling
ing that prevents injury to the body, when worn in battle (The one another horrific medical stories. The reason as to why
Free Dictionary, 2013). While observing critical care nurses this was used as a coping skill was not very evident. These
in their work environment, it became evident that there was nurses also took up hobbies or did other entertaining or relax-
a difference between their exterior personality (armor) and ing things at home as a way of coping: “I want to be away
the inner, protected personality. One nurse said, “I don’t from work and it’s not that I hate my job. I just don’t want to
think people at home understand what you’re going through live my work.”
at work and people at work also don’t know who you are They often discussed the possibilities of finding other
when you’re at home.” employment, and some even made plans up to a certain
Armor display was earmarked by verbal and non-verbal point. It was like a “great escape” for them. Most nurses
communication and by constantly applying coping skills and never carried through their plans and kept on making new
adapting. Pride in the critical care nursing culture is another ones. One nurse explained this by saying, “None of them
aspect of armor display, as well as the critical care nurses’ actually knows what they would like to do. So I think, it’s
utilization and display of knowledge and practical skills. kind of a utopia where you told yourself I would escape to or
hide in, to get rid of all these negative things.”
Verbal and non-verbal communication is a part of critical care These nurses made use of introspection and reflection on
nurses’ armor display.  CCU nurses were perceived by others their own acts and thoughts, which led to a mind battle about
as being cold and hard. They were observed to carry on with the hard decisions they made and the consequences, as evi-
normal ward activities after the death of a patient. In a sense dent in this statement: “That’s the right thing, I did the right
they were actively withholding emotions—keeping them at thing. But my heart kept telling me no.” They experienced
bay. They became emotionally disconnected. This might be guilt and other emotions about end-of-life decisions and rou-
by choice or even a subconscious skill that had developed tine actions, followed by the death of a patient, until they
over time. During an interview, one nurse said, “You tell obtained inner peace and moved on. One nurse said, “I felt
them that you are sorry. But you keep so much of yourself sick about it for days afterwards!”
back.” Another nurse remarked, “I can really cry . . . No, I Religion might also play a part in restoring peace, as is
don’t normally cry at work, I cry in front of my husband. I’ve evident by this nurse’s admission: “I go home and I work
got a soft heart, but I will not cry at work.” through my day and think through my day and I pray and
Other verbal and non-verbal communication also included read, my religion is very important to me.” They often asked
the use of a different verbal language. They used sarcastic themselves why they were critical care nurses and why they
remarks, their own abbreviations and medical terminology, did it. One nurse wrote in her diary, “This is a continual
and might refer to patients by their diagnosis. A diary inscrip- search to purpose—purpose of why—why am I doing this?”
tion in support of this stated, “One bed open after a death— They realized who they were, what it demanded from them,
for the doctor’s Aorta bypass.” Nurses complained about and how it had changed them.
difficult circumstances within their unit. Complaining might
have been a way of coping with the demands of the CCU. The importance of critical care nurses’ pride in the CCU
They were sometimes described as moody and irritable. This culture.  Pride and territorial behavior were witnessed in the
was mostly observed during a very busy shift. It was wit- organization of the critical care nurses’ work setting—
nessed on many occasions, and during interviews it was specifically the area surrounding the patient. After nurses
6 Global Qualitative Nursing Research 

had been allocated to patients for the day, they usually pro- CCU was a fast-paced, stressful, and noisy environment
ceeded by making a point of reorganizing their work envi- which had many technological challenges. These elements
ronment to their own set of standards. This included the bed by themselves were small, but added together on a busy day
area and the paperwork related to the specific patient. During led to a build-up of frustrations as evident in this diary
an interview, one nurse explained, “You want to be good, you inscription: “The telephone just keeps on ringing. The tele-
want to be good at your work.” phone and alarms are something from hell . . . I am really
Critical care nurses stay in their closed environment and sick of broken equipment!!!”
work with the same people for a long time. When confronted They were exposed to various infections: “There was
or criticized by others, they tend to defend their work meth- Acinetobacter infection in the unit; we were all stressed,
ods and even their colleagues vigorously. They feel strongly because you feel it’s your fault.” They worked long hours
about their unit. Even the ideals and standards of care were and difficult shifts. A few nurses mentioned these issues dur-
defended. One nurse stated, “What happens there is ours . . .” ing the interviews: “The hours are too long. Twelve hours are
These nurses also defended their occupation, and they far too long”; and “You don’t actually have a choice, but I’m
perceived most people outside of the unit—even other hospi- not a person for night duty.”
tal personnel—to be unaware of and having no idea as to Ethical issues, including end-of-life decisions, are a part
what their work entailed and how they functioned and sur- of any CCU environment. These issues were very real, and
vived within that environment: “I will introduce myself as a CCU nurses had strong feelings about them. Death and expo-
nurse, because you know what, they in any case don’t know sure to traumatic situations were unavoidable elements of the
what an ICU nurse is.” CCU, and nurses were confronted with these on a daily basis:
“The doctor said that she must wean off the inotropic drugs,
Critical care nurses’ utilization and display of knowledge and which support the patient’s blood pressure, but the patient
practical skills are a part of their armor display.  Armor display already had a poor blood pressure. The nurse did not feel
could also be seen in an emergency situation, when nurses comfortable in doing this.”
took control, remained calm, and ready to handle a crisis. In
a way they were armed with knowledge and practical skills Despondency observed due to the high work load in the
to meet the challenges of the CCU. Many nurses also CCU.  Despondency with the demands of handling the work
remarked on the necessity of these qualities in a CCU nurse. load was observed and mentioned by all of the nurses:
This was clearly evident in the following remark: “Here you “Because the problem here—it is actually the staff . . . we
must be able to take your patient, and you must be able to run don’t have a lot of nurses anymore.” The work load was
and know what you’re doing.” mostly defined by staff shortages and the company policies
Keeping set routines was a necessary action for these surrounding it, the administrative load, and students. Stu-
nurses to handle stressful situations. When any emergency dents were seen as contributing to the work load, rather than
interrupted this routine, the nurses adapted, handled the cri- helping: “If you have a full unit with very ill patients and
sis, and then returned to the routine tasks as if nothing had then to teach someone from scratch . . . No, then I rather
happened. They enjoyed the challenges of applying their work with one more patient . . .”
knowledge and skills, which became instinctive actions in The researcher observed that as soon as the work load
certain situations. stressors increased, it led to increases in conflict among col-
leagues. It also threatened patient adoption, the nurses’ main
Patterns of Despondency Because of the focus; thus leading to more stress at work and less job satis-
Demands to Adjust to the Critical Care faction when coping skills failed. They were furthermore
unable to provide the care they desired for their patients. This
Environment was written as a diary inscription: “Work allocation—diffi-
The researcher often observed despondency among these cult, here are no strong people today and the unit is filled to
nurses which was a consequence of the demands to adjust to the brim.” Many a time, these nurses accepted more patients
the CCU environment. than they felt comfortable with taking responsibility for.
Agency staff who did not permanently work in the spe-
Despondency observed due to the exposure to the CCU cific unit was not a solution toward decreasing the work
elements.  The way in which nurses were introduced to the load; instead, agency staff often caused more work and a
CCU played a vital role in the time they took to adjust to this decrease in standards of care. This was said during an inter-
environment. One nurse stated, “I don’t think anyone adjusts view: “Many of these agency nurses only come for the
to the ICU immediately, it takes time.” CCUs have many money. They can’t be bothered about the rest.” Shift leading
cognitive challenges, and therefore nurses also require con- proved to be very difficult in a CCU that was short staffed
tinuous training. The need for training was not always met in and with new staff or students allocated to very ill patients,
this environment, and this inadequacy became and remained as noted by some of the shift leaders: “You are the shift
an added challenge for adjustment in this environment. The leader and you have to look after a ventilated patient and
Scholtz et al. 7

another one and then you take the shift also”; and “You had . . . in a certain sense it is actually good, it pressures them to
to handle all the stress and nobody could think for them- go and learn.”
selves, because they didn’t have the knowledge.” Conflict among colleagues was a real problem in this
Added to the physical and emotional work load was an CCU and was confirmed throughout the diaries and inter-
administrative load, which was considered to be equally views. The reason for the conflict might be anything from
important. Every action was written down and a few extra personality clashes to non-support in team efforts. While the
forms for reporting and various committee activities added researcher was observing these nurses, she found them to be
up to the administration within the unit. It was stressed that irritable when overly tired and this, in the end, led to conflict.
“the paperwork repetition is far too much.” Critical care It also became clear from this diary inscription: “Today half
nurses preferred to nurse their patients without the added of the personnel in the unit were irritated and impatient . . . I
administration surrounding it. Their issues with administra- think everybody is tired.”
tion worsened due to staff shortages and the added patient These nurses were of the opinion that it was necessary to
load. provide one another with emotional support. Besides emo-
tional support, critical care nurses supported one another in
work activities and would criticize one another, mainly in an
Patterns of Sibling-Like Teamwork
effort to teach. This method was not always constructive.
The importance of teamwork was surprising. Each individual
nurse interlinked with one another, and that seemed to be Patterns of Non-Support From Management and
essential toward the effective functioning of the CCU
environment.
the Medical Doctors
Nurses could not provide nursing care to critically ill patients
Bonds of cohesion observed among critical care nurses. They on their own. They needed a multi-disciplinary team effort.
seemed to know one another’s strengths and weaknesses. They were aware of this fact, but they received little support
One nurse said, “We know each other’s shortcomings and we from management and medical doctors. This created a more
know each other’s strong points and . . . that’s what makes stressful work environment.
the work easier in the end.”
They learned to work and grow together. In an emergency, Behavior and interaction of critical care nurses influenced by the
it was considered vital to know your colleagues and to apply perceived non-supporting role of management. These nurses
their knowledge and skills in a way that gives the patient the perceived hospital management as rather focusing on finan-
best chance of survival. These nurses complemented one cial issues and not on patient care as they (the nurses) did.
another. A very important element of this pattern was bonds They perceived the hospital and even the unit management to
of cohesion, as noted by this statement: “We must all use lack understanding and support in their situation: “I feel that
each other to make a stronger team.” management doesn’t give us the support that they should.”
The shift leader, an experienced CCU nurse with addi- This was mentioned often with regard to help where staff
tional training or a master’s degree in CCU nursing, is shortages and problems within the medical team became a
selected on a daily basis to manage and guide other team crisis: “Here they have this idea that you should just cope.”
members in the CCU; other leadership within the unit was Non-support was also evidenced by the nurses’ perception of
also considered an important aspect in the bonding of the inconsistency, favoritism, and lack of fairness. The influence
team. The team leader could either improve the team’s atti- and effects of the leadership style in the unit were sometimes
tude toward each other or have the opposite effect: “I think questioned, especially when these nurses became frustrated
when the shift leader is unsure of herself, then she makes the with their circumstances at work.
whole team that works with her unsure.”
Behavior and interaction of critical care nurses influenced by their
Interpersonal relationships characterized by fight and support ambivalence toward medical doctors.  The relationship between
relationships among critical care nurses.  Teamwork took on a critical care nurses and medical practitioners was considered
sibling-like fight and support or love and hate relationship. to be one of non-support. Nurses sometimes received degrad-
One nurse said, “And you later become like family to each ing feedback and unreasonable demands or reactions from
other and . . . then you also fight.” Teamwork was considered the doctors. They considered it important to be assertive
the most important aspect of making critical care nursing when it came to the doctors, but not all nurses could cope
work. The nurses saw each other as dynamic, assertive, with this, and communication between them and the doctors
strong-willed personalities, which led to challenging inter- was poor. This included illegible written prescriptions and
personal relationships. It was considered essential for the misunderstanding of verbal orders. It was evident that there
CCU environment. Competition over position and knowl- was difficulty with obtaining prescriptions from doctors.
edge was seen to have a positive or motivational, and a nega- This placed these nurses at a medical-legal risk and could
tive effect. The opinion of one nurse was “competitiveness also influence the efficacy of treatment. Unavailability of or
8 Global Qualitative Nursing Research 

uninvolved doctors were another serious problem for these responsibilities toward the patient. Evans et al. (2010)
nurses as evident by these statements: described their experiences of critical care as being in a con-
stant, psychological state of change. These nurses claim that
But some of the doctors put their cell phones off. Others just it is important to have a strong personality to persevere
transfer the patient to us, so that they won’t be bothered during throughout difficult situations. Armor display might describe
the night. some of the characteristics of such a personality.
The four aspects described as a pattern of armor display
None of them really takes ownership of the unit . . . And all of were found throughout recent literature. In O’Connell’s
them expect that you need to have things precisely the way they
(2008) reflection, she suggests a degree of emotional detach-
want it.
ment when working with critically ill patients. Stievano, De
Marinis, Russo, Rocco, and Alvaro (2012) affirmed that
Yes, and if they really don’t get the doctor, then we act, but not
always within our scope of practice, but that which we know we nurses experience feelings of achievement of professional
have to do in a crisis, you know. dignity when they have the authority to make decisions and
utilize their knowledge and skills.
Most critical care nurses were of the opinion that they Critical care nurses’ utilization and display of knowledge
should stay professional despite any perceived unprofes- and practical skills were described in many studies to affect
sional conduct from the doctors or even their lack of support. nurses’ competence and confidence, and are essential ele-
It was important for these nurses to be acknowledged and ments in the culture of critical care nurses. Hughes (2012)
respected for their role in the patient’s care, and they wanted stated that critical care nurses, at times, knew exactly what
to be included in the decisions regarding patient care: the patient needed and just asked for a prescription, based on
“Sometimes we know what is better for the patient. They an understanding of the clinical manifestations they had
don’t want to hear it. They’ve got their own preconceived observed in the patient. Stievano et al. (2012) remarked that
ideas about how they will do things.” for these nurses to gain competence, they required life-long
learning. This is accomplished by participation in continuous
professional development, which might lead to more self-
Discussion esteem and awareness of their role within their culture.
Five patterns of behavior and interaction were identified in Nurses in their study felt that proving that they were compe-
this study. In the pattern of patient adoption, it was revealed tent and well educated was the only way to earn the respect
that critical care nurses focused on their patients and their and dignity of other health professionals.
behavior, and interactions were influenced by the role of the The critical care culture included patterns of despon-
CCU patient’s family. dency, because of the demands to adjust to the critical care
Several studies included the importance of the patient and environment due to the exposure to the CCU elements and
the patient’s family in the work lives and experiences of criti- work load.
cal care nurses. Vouzavali et al. (2011) described the nurse– Although despondency was not directly described in the
patient relationship as a “shared world” (pp. 143, 144, 147). literature, it was affirmed by related terms. Wiegand and
Nurses in their study saw the patient as “belonging” to them, Funk (2012) found that moral distress, as a result of chal-
and they remarked that they experienced “intense relation- lenges faced in the critical care environment, had frequently
ships” with their patients. Ulrich et al. (2007) affirmed that been experienced by critical care nurses in practice. Moral
nurses experienced recognition to be most meaningful when distress in their study resulted in nurses feeling disappointed,
it came from patients. Wiegand and Funk (2012) found that distressed, and experiencing psychological and physical
even when nurses were faced with ethical dilemmas, they exhaustion. These nurses considered leaving their positions
would make decisions that respected the obligations to their and described feelings of decreased morale and reduced job
patients. Hughes’s (2012) participants said that they would satisfaction. One could argue that despondency would be a
do anything to assist their patients. Vandall-Walker and Clark result of moral distress.
(2011) stated that critical care nurses either supported family Cummings (2011) stated that nurses’ intent to stay at an
members or set up barriers that family members had to work institution is affected by certain factors or elements that
at to breach, confirming the role of the patient’s family in cause stress in the critical care environment. Although
patient adoption. nurses’ intent to stay within the critical care environment was
The pattern of armor display involved verbal and non- not explored in this study, the reality of despondency due to
verbal communication; coping skills and adaptation; the the CCU elements and work load might affect critical care
importance of the critical care nurses’ pride in the CCU; and nurses’ intent to stay within this environment.
their utilization and display of knowledge and practical A pattern of sibling-like teamwork was characterized by
skills. bonds of cohesion and fight-and-support relationships. This
Vouzavali et al. (2011) stated that the critical care nurse was supported by several studies. Evans et al. (2010) found
becomes “both hero and captive” (p. 144) in her work and that nurses deliberately develop supportive relationships
Scholtz et al. 9

among colleagues to create feelings of safety and belonging. Further exploration with regard to the other actors within this
Burston and Tuckett (2012) stated that interpersonal relation- setting could be valuable, especially after the initial data had
ships directly influenced the nurses’ experience or their real- indicated the role of the entire nursing team, medical doctors,
ity of moral distress. Price (2013) affirmed that the effective and management in the critical care nursing culture. Increasing
functioning of the critical care nursing team was affected by numbers of enrolled nurses now utilized within the critical care
“power relationships” among team members and, despite setting may have a significant impact on the critical care nursing
frustrations, teamwork within the CCU was important. culture. Enrolled nurses may also be affected by their role adjust-
The final aspect of this culture included patterns of non- ments within the critical care setting. Studies with the focus spe-
support from management and the medical doctors, as the cifically on enrolled nurses in this setting could not be found.
behavior and interactions of critical care nurses were influ- Another limitation of this study was the lack of response
enced by the perceived lack of support from management from participants toward keeping a diary, resulting in a loss
and nurses’ ambivalence toward the medical doctors. of possible personalized accounts that could have added
The role of management was mentioned in a few recent value to the results. Nurses found it difficult to keep a diary,
studies. According to Stievano et al. (2012), emotions expe- but they were used to completing a structured CCU chart and
rienced by nurses in their study ranged from feelings of adding a progress report to this factual chart to describe their
abandonment by their organization to a lack of respect and actions, decision making, and conclusions. It might be useful
belonging. Results were further supported by Cottingham, to rather structure diaries used for data collection in future
Erickson, Diefendorff, and Bromley (2013), who discussed studies in a similar format, where nurses can provide facts
the effects of exclusionary practices, including being ignored about their work environment and then write a report based
by managers. Brunault et al. (2014) showed that nurses’ on reflection, related to these facts.
quality of work life is improved by teamwork and perceived
organizational support. Conclusion
The perceived non-supporting role of the medical doctors
was supported by Stein-Parbury and Liaschenko (2007). The results of this study indicated the existence of a critical
They concluded their study by stating that nurses felt “aban- care nursing culture. The implication of changes that may
doned, rejected or ignored’ when they asked assistance from either have a negative or positive impact on each pattern of
medical doctors. Hughes’s (2012) participants described behavior and interaction in the CCU or the culture of critical
instances where physicians, not present in the unit, disagreed care nurses should be considered in all efforts to facilitate
with the nurses about their assessment of a patient, stating recognition of wholeness in critical care nurses. After the
that the nurses were wrong. Stievano et al. (2012) found that completion of this case study, the selected critical care unit
a poor nurse–physician relation leads to a loss of profes- changed their RN–patient ratio to a ratio of greater than one-
sional dignity, high turnover nursing rates, a decrease in the to-two RNs per patient, but they included other categories of
quality of care, and a lower quality of care perceived by non-registered nurses. Despite the findings of a study per-
patients. formed by Tschannen and Kalisch (2008) who found that,
The aim of this study was an exploration of the culture of when more registered nurses than enrolled nurses were used
critical care nurses which resulted in the identification of five in the critical care setting, the patient’s length of stay
patterns of behavior and interaction among nurses in a CCU. decreased significantly, changes like these will still be imple-
Facilitating recognition of wholeness in critical care nurses mented and affect the culture of critical care nurses.
requires an understanding of the critical care nursing culture The complexity of the patterns of behavior and interaction
that includes these patterns of individual or group behavior within the critical care culture brought to light the need for
and interaction of critical care nurses with one another, their transformation in the critical care nursing culture. Although
patients, and other health care members. not described in this article, we developed a model to facilitate
constructive patterns of behavior and interaction in CCUs,
based on the findings of this study. An awareness and under-
Limitations standing of the patterns of behavior and interaction in the CCU
A limitation of this research was the exclusion of enrolled add to the knowledge base of critical care nursing and empower
nurses from the study. Enrolled nurses or staff nurses in critical care nurses in the transformation of their practice.
South Africa receive a diploma in nursing from a nursing
education institution usually after a study period of 2 years, Declaration of Conflicting Interests
with the outcome of being dependent general nursing prac- The authors declared no potential conflicts of interest with respect
titioners under the supervision of RNs. Due to the nature of to the research, authorship, and/or publication of this article.
the in-depth exploration which produced a large amount of
data to be analyzed, only registered critical care nurses Funding
were selected to participate in the interviews and to keep The authors received no financial support for the research, author-
diaries. ship, and/or publication of this article.
10 Global Qualitative Nursing Research 

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